REP51340

• Permit No: M1976027
• IBM Index Class Name: Report
• Doc Date: 5/18/2004
• Doc Name: Annual Report and Fee
• From: Nielsons Inc.
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Nielsons, Inc.
M-1976-027
Craig Pit
June 17, 2004
RECE
MAY ~
Division ~tMine.
$688.00 (Due on or before your anniversary date)
La Plata
Mq~c~~~FO
r~
~'disioaaf~ner 81~~y
a/SandCoDtoBY
According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator
shall submit the annual fee, a report and map showing the extent of current disturbances to affected land,
------i~eclamafion-aceemplished-to-date-and-during-the-preceding-yearnew-disturbances-that_are-anticipated,to_occur~ _ _
during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning
of active operations, and the date active operations ceased for the year, if any.
Please attach ynnr revised written annual reRprt and annual r ngn rt matn to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact:
Permittee Name:
Craig Wickstrom
Nielsons, Inc.
Address: 22419 CR G
Phone Number:
Fax Number:
P.O. Box 1660
Cortez, CO 81321
[phone]
[phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are enclosed.
~ r
Signature o Corporate Officer, Owner, or Designee
S/~~
Date ~'-Z